Abstract

Communication between healthcare professionals is a key aspect in patient safety especially when dealing with patients with musculoskeletal trauma. The change of junior doctors’ working patterns within the last decade and a multidisciplinary approach has resulted in more healthcare professionals being involved in any one patient’s care. A robust handover and communication tool is essential in ensuring patients’ safety and to allow efficient service coordination. We compared the use of a simple traditional template-based handover system with an electronic interactive database developed using Microsoft Excel specifically designed as a handover tool and to coordinate acute trauma referrals to the orthopaedic department in our hospital. We compared the adequacy and accessibility of patient details and clinical information as well as assessing these systems as tools to facilitate coordination of patients with trauma. Data from both handover systems were collected prospectively over the period of 12 weeks and analysed for the degree of missing information based on the General Medical Council and British Medical Association guidelines for safe handover. A questionnaire was also handed to members of the multidisciplinary team to assess their impression of each handover system on coordination and management of the trauma service. Our study showed a significant reduction in missing information in the electronic database handover system in multiple domains (p<0.001). Our survey of 29 healthcare professionals also showed a significant improvement in their perceived ability to manage acute trauma referrals, coordinate patients awaiting surgery and in accessing previous handover discussions (p<0.001).

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Introduction

Effective communication between healthcare professionals is vital in maintaining high standards of patient care. This is particularly important in the high turnover, ever changing environment of musculoskeletal trauma. The change of working patterns of junior doctors over the last decade as a result of the New Deal and the European Working Time Directive has resulted in more doctors involved in the management of any one patient. This has increased the frequency of handovers taking place between doctors.

Over the recent years, the advantages of a multidisciplinary approach have been seen with the involvement of the greater care team, including the medical team, theatre staff, trauma coordinator and other allied healthcare professionals. To this end, the effective sharing of information between these groups facilitates a more cohesive approach to patient care and enabling appropriate prioritisation of cases.

This modern environment of providing care has led to the need for a system to store and retrieve patient clinical information and management plans in the acute setting. A system that is easily accessible and intuitive to use should result in a more efficient and coordinated approach in managing patients with trauma.

There have been various handover methods that have been described with varying efficacy.1 Studies have shown that handover sheets are the most effective method of retaining and passing on information.2 The General Medical Council (GMC) and British Medical Association (BMA) have recognised the importance of effective handovers and have published guidelines for safe handovers.3

We describe the use of Microsoft Excel as a database for acute referrals to the trauma and orthopaedic department at our hospital. We compare the difference between this electronic database system (EDS) and the traditional template-based handover system (THS) with regard to adequacy of information on handover sheets and coordination of trauma.

Background

Prior to November 2015, the THS used a spreadsheet containing columns for patients’ details, hospital number, admission date and time, breach time for neck of femur fractures, diagnosis, clinical details, location, outstanding jobs and plan. For each admission day, this handover sheet was printed and saved to create a new file, spreading patient information over multiple files led to difficulties in retrieving data

After the morning trauma meeting, patients who require surgery will also be identified and planned procedures confirmed. Traditionally, information of these patients was handwritten on a dedicated whiteboard of pending trauma. In order to protect confidentiality, details on the board were limited to initials, age, hospital number and planned procedure. After prioritisation of all pending surgery cases, a trauma list was generated by transferring patient information and planned procedure onto a preprinted template. This system required the triplication of documentation, which could introduce errors into the system.

It was clear to see that this system did not allow easy access to management plans discussed at trauma meetings for members of the multidisciplinary team (MDT) who do not regularly attend the morning meeting. Scarcity of information on the trauma board made prioritisation of and coordinating trauma cases challenging.

Methods

In order to review the completeness and adequacy of information provided by at handovers, the GMC/BMA guidelines for safe handovers were used to ascertain a minimum dataset required for effective and safe handovers. Box 1 shows the agreed departmental minimum dataset for required information at handover and trauma meetings.

Box 1

Minimum patient and clinical information for handover

Demographics

Must contain name, date of birth and hospital number

Date of admission

Consultant details

Admitting doctor

Current location

Diagnosis

Injury site

Injury side

Clinical details

Comorbidities

Planned management

Planned operation

A questionnaire was completed by each member of the multidisciplinary team assessing the ease of coordination of trauma comparing the two systems. As there is no current valid questionnaire available to use for our type of study, we developed a questionnaire which covers three key domains: keeping track of acute referrals, keeping track of patients requiring surgery and obtaining information and plans from previous trauma meeting discussions. Figure 1 is a sample of the questionnaire distributed to members of the multidisciplinary team.

Study design and analysis of data

Data for this study were collected prospectively. Data regarding adequacy and completeness of information from the THS were collected using the daily trauma meeting handover sheets over a 6-week period between October and November 2015.

The EDS was introduced exclusively in December 2015 after a trial period of running in parallel with the THS for 2 weeks in the month of November 2015. Similarly, data for the electronic system were collected prospectively during a 6-week period between February and March 2016. Questionnaires were distributed to members of the multidisciplinary team involved in trauma care at the end of each 6-week period (November 2015 and March 2016). Data collected were analysed using χ2 test to compare the difference in proportion of missing information and Student’s t-test to compare the means in the results of our survey. All statistical data analyses were performed using SPSS for Macintosh V.23 (IBM, 2015).

Design of programme

Technical aspects

The software was designed to have a familiar user interface and to be intuitive and clinician centred. The software had to be compatible with the current information technology environment present in the National Health Service (NHS) and ideally not cost too much to set up. With this in mind, the author decided to develop the software with Microsoft Excel as its foundation.

Entering and editing information

Entering patient information and clinical data is performed using a form with clearly labelled text boxes and prompts, using free texts or drop-down boxes. In order to facilitate complete data entry, the database will not allow any of the boxes to be left empty when adding new patient details.

Using the information provided, details of the patients’ acute episode will be stored permanently on the database. This singular storage location forms the basis of a centralised information hub for members of the MDT and avoids spreading of information across multiple files. The software is then able to use information from this database to produce customisable lists such as a handover list, a list of patients awaiting surgery and even a trauma list. These lists are produced without the need to re-enter patient details or clinical information. Examples of generated lists are shown in figures 2 and 3, respectively.

Example of trauma list and pending trauma managed by the electronic database.

The database has also been designed to allow information to be easily editable and to be run in the background during handover meetings. This feature allows the most up-to-date plans to be entered into the database as management plans are being formulated at the trauma meeting.

Confidentiality

As our database contains confidential data, security of the information was paramount during design of the database. The software has a dual-layer password protection and is stored on a shared drive on the hospital computer network. The database is only accessible within the trust and only preapproved users are given access to the shared folder. This allows better monitoring of users having access to confidential patient information.

To further protect information, the database has also been designed to automatically log out if left idle for more than 10 min. Infrequently, users of the software have been called away to deal with an emergency without logging out of the database. This feature will minimise unauthorised access to confidential patient information if left unattended.

Results

Overall, 601 patients were included in this study, 301 in the control group (THS) and 300 in the study group (EDS). There were 294 men (48.8%) and 307 women (51.2%) with a mean age of 55 years old (range 3 months to 105 years old). A total of 237 (39.6%) patients required surgical intervention and of these, 82 (34.6%) were neck of femur fractures. Forty-six (19.4%) patients requiring surgery were treated as semielective and were not admitted as inpatients. Table 1 summarises the statistical differences between the two groups comparing adequacy of handover information.

Summary of percentages and relative risk of handovers with missing information

We handed questionnaires to 29 doctors and health professionals involved in the MDT managing patients with trauma in the hospital. The response rate was 100% and comprised consultants (9), middle grades (9), senior house officers/foundation year 2 doctors (3), nurses (7) and site managers (1). Results of this survey are summarised in table 2.

Discussion

Poor handover between doctors, nurses and other members of a multidisciplinary team is a common cause of error in hospitals and a major preventable cause of patient incidents.4 In NHS hospitals throughout the UK, there are still no standardised tools or procedures for improving the continuity of care and safety of information transfer between teams of physicians and surgeons caring for patients. In 2007, the Royal College of Surgeons issued guidelines for safe handover to help alleviate the issues relating to handover caused by the European working time directive and movement to a more shift-based system that is now commonplace across all specialties.3 There have also been many other reports highlighting the importance of good quality and accurate handover in avoiding significant lapses in patient safety.5 6

There is a progressive move towards utilising digital and computerised technology to benefit healthcare, and high-quality, modern solutions are vital in achieving major gains in quality and safety.7 Many electronic systems that assist in physician-to-physician handover are now widely in use and the current literature broadly supports the use of such tools. Several projects in the field of trauma and orthopaedics have looked into optimising the handover process including the work by the group from University College London Hospital who have developed TraumaPal.8 Systematic review, however, highlights methodology issues precluding the attainment of patient outcome measures for many of these studies, therefore making assessment of the true impact of these systems difficult.9

When embarking on this project, we had two clear aims: to improve adequacy of information at handover meetings, and aid members of the MDT to coordinate care for acutely injured patients with trauma.

There are several features built into our software to help us achieve our aim of improving adequacy of information at handover. This includes prompts at the entry form level that do not allow the user to proceed unless all the data boxes are filled in. This encourages complete and accurate data entry and results of this are reflected in the significant improvement in consistency of data recorded in comparison to the original THS. We also felt that by using a combination of structured data entry and free text entry, we achieve both a high level of consistent data but also give users the ability to elaborate on clinical information in specific areas. This allows users to cater for the diversity of both our patients and their injuries. Structured data entry has been shown to be beneficial in minimising error and ensuring quality of data recorded and also has the benefit of facilitating easy searching and audit of data.10 However, studies have shown that standardised data entry should not entirely replace free text entry especially from the perspective of trauma and orthopaedics where injuries and diagnoses can vary substantially.10 We feel that this flexibility in our programme helped user compliance and uptake.

Our software has also been designed to run in the background during the morning trauma meeting allowing immediate documentation of plans made by the responsible consultant. The advantage of this is twofold. First, it serves to record decisions and plans at time of discussion thus minimising mistakes and information loss due to recall. Second, this practice is valuable for patients waiting for surgery at home. Often clinicians will not have the full set of notes of these patients with semielective trauma apart from their accident and emergency notes and plans formulated during trauma meeting can easily go missing. We also found that plans for patients who do not require surgery and are reviewed in the fracture clinic benefited from being documented directly into the database. Clinicians can simply log into the database, search for patients and review discussion made at the trauma meeting and discuss this with the patients in clinic, without having to resort to memory or referring to the responsible consultant to confirm clinical plans. This exercise also allows for accurate minuting of discussions, which has become a governance issue over recent years.

The survey carried out in our department showed that the software used helped increase the ease of coordinating trauma care. By acting as a central database for patient information, members of the MDT can quickly bring up up-to-date plans made for patients from trauma meetings without having to go through patients’ notes or refer to minimal information on pending trauma boards. The software allows the clinician the ability to view all outstanding trauma cases in one view together with relevant clinical history and planned procedure and this helps efficient prioritisation of clinical cases with minimal hassle. This real-time snapshot of the department’s trauma load allows better allocation of departmental resources and theatre list utilisation, hence enabling the department to better cope with the peaks and troughs of trauma care.

A further advantage this database has compared with the traditional THS is data audit. Having a record of all acute referrals to the department in one single location allows users to quickly collate data for various projects and analyses. This can be useful when monitoring departmental performance in management of injuries such as neck of femur fractures, data collection for audit projects or other clinical governance purposes.

Being developed based on Microsoft Excel platform, our system has a further advantage of being cost-effective. As most hospitals and trusts already possess licenses for Microsoft Office products, this key feature ensures that trust does not have to purchase and install any additional software in order to have this system running in all their networked computers. This cost factor may help encourage more departments and trusts to migrate to an electronic-based system from a paper-based system.

We accept that there are limitations to our EDS. The department is still heavily dependent on the handover sheets for the running of the morning trauma meeting. Because of this, rarely, the software is not running in the background during the trauma meeting and plans or discussion from the meeting is updated on to the software at a later time. This practice again might introduce error into the system secondary to information loss due to recollection or transcribing error. Having an additional computer to allow the database to be updated during the meeting may be a solution to this problem. Due to Microsoft Excel limitations, only one user can both view and write new information into the database at any one time. Other users can view the database but not enter new data until the earlier user logs off. However, due to the fact that majority of the data entry into the software is carried out by the junior doctor on call, problems with multiuser write access have not been a major issue at our institution.

Our experience highlights that effective implementation of such a system requires the full support of the department at all levels. This support is essential to prevent data gaps from emerging due to varied methods of capturing admissions data. By implementing our system as a universal and singular method of recording these data, we were able to ensure high compliance and hence an accurate assessment of the success of our system. Most importantly, we feel such a system allows for enhanced patient safety and care by acting as a central hub for patient information. This, we predict, is vital for the future of trauma care, which often involves a diverse multidisciplinary team in multiple sites by allowing improved access to accurate information and enhanced service coordination across the whole department.

In conclusion, our study showed how the production of a low-cost database system can improve quality of information at handovers and increase efficiency of junior doctors by reducing duplication of work involved in acute take referrals. This reduction of work duplication reduces the chance of error introduction and allows more time to be spent on direct clinical care. Acting as a central hub of information, this software has also conferred better communication and hence coordination of trauma service to our multisite and multidisciplinary department.

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